Malnutrition is one of the most widespread public health
problems facing India today. Among the highly susceptible groups
are infants and toddlers (0-3 years old), who constitute nearly
10% of Indian's population. Unfortunately, they are largely
ignored from a nutritional standpoint [1]. There is now a growing
realization that malnutrition is not only a problem of food
supply but can also be a function of more complex big-social and
behavioural determinants affecting child feeding and rearing [2].
In the present study, therefore, we have attempted to identify
various socio-economic, environmental, and maternal factors and
the child-feeding and childrearing practices of mothers that
affect the nutritional status of infants and toddlers.

Methods and materials

Sample

Ten urban slum areas in the city of Baroda and nine rural
villages in the Panchmahals and Bharuch districts of Gujarat
state were randomly selected for the study. These slums and
villages did not have any ongoing nutrition programmes. All
children 0-3 years old living in the selected study areas and
available during the survey were the subjects (N = 786).

Tools

Three pre-structured, pre-tested forms - family, maternal, and
child - were used to collect the required information on each
subject.

Factors studied

The factors studied for their association with the nutritional
status of the children included family type, family size,
religion, and caste; per capita income and land holding; water
facilities, house sanitation, and toilet facilities; mother's
educational level, working status, child-care time, height,
weight, and obstetric history; breast-feeding, bottle-feeding,
and weaning practices; and the child's calorie and protein
intake, sex, birth order, and clinical and immunization status.

Anthropometric measurements

All the children were weighed using a Salter scale and were
classified on the basis of their weight for age, using the 50th
percentile of the Harvard standard and the classification of the
Indian Academy of Pediatrics [3]. The mothers, heights and
weights were determined by standard procedures.

Dietary intake

The 24-hour dietary intake of each child was determined by
interview and observation [4].

Statistical analysis

Percentages were calculated and the chi-square (x2) test was
used to identify factors significantly associated with the
subjects, nutritional status [5].

Results

The distribution of the children by nutritional status and age
group is shown in table 1. As is evident, the infants (birth to 1
year old) had better nutritional status than the toddlers (1-3
years old). A higher percentage of the infants than of the
toddlers were in the normal category (52% versus 20% ).
Furthermore, while only 6% of the infants were severely
malnourished (grade III or IV). 18% of the toddlers fell into
this category.

Factors associated with the nutritional status of
infants

The factors found to be significantly associated with the
nutritional status of the infants are presented in tables 2-4. As
is evident, the infants from families with a higher per capita
income (Rs 100 or more per month); those whose mothers were 18-30
years old, were over 145 cm tall, and weighed over 45 kg; and
those who had no clinical signs of nutritional deficiency had
better nutritional status than their counterparts. These findings
indicate that the nutritional status of infants is affected more
by maternal nutritional status (judged by the height and weight
of the mother) than by other socio-economic, environmental, and
child factors.

Factors associated with the nutritional status of
toddlers

Tables 5-8 present the factors that were significantly
associated with the nutritional status of the toddlers.

Data in table 5 show that a number of socioeconomic factors
were involved. Those toddlers whose families were Muslim, were
from castes other than the Schedule castes and Schedule tribes,
had more than nine members, had a per capita income over Rs 100
per month, and (in the rural areas) had land holdings of more
than two hectares had better nutritional status than their
counterparts.

As for environmental factors, toddlers from homes having
access to potable water and sanitary toilet facilities had better
nutritional status than those using non-potable water and having
unsanitary toilet facilities (table 6).

TABLE 1. Distribution of children by nutritional status and
age group

Age(years)

Nutritional
status

N

I

II

III-IV

0-1

52 (161)

26 (81)

16 (48)

6 (18)

1-3

20 (94)

36 (172)

28 ( 133)

17 (79)

0-3

32 (255)

32 (253)

23 (181)

12 (97)

In this and the following the
principal data arc percentages: figures in parentheses indicate
the number of subjects. Nutritional status is calculated on the
basis of the 50th percentile of the Harvard standard and the
classification of the Indian Academy of Pediatrics: N = normal;
I-IV are grades of malnutrition.

TABLE 2. Association between
family per capita monthly income and the nutritional status of
infants

Income

Nutritional
status

N

I

II

III-IV

<=Rs
100

51 (97)

23 (44)

17 (32)

9 (17)

>Rs
100

54 (61)

31 (35)

14 (16)

1 (1)

x2=980: P<.05:df=3

TABLE 3. Association between maternal age, height, and
weight and the nutritional status of infants

Toddlers whose mothers had some
education had better nutritional status than those with
illiterate mothers, as did those whose mothers did not work and
whose mothers weighed over 45 kg compared with those whose
mothers worked and whose mothers weighed 45 kg or less (table 7).

As for the various child factors
studied, it was found that male toddlers had better nutritional
status than female toddlers, and that more toddlers without
clinical signs of nutritional deficiencies fell into the normal
category than those exhibiting one or more such clinical signs
(table 8).

Discussion

The results of the present study
indicate that the infants had better nutritional status than the
toddlers. This has been reported by other investigators as well.
In a study from Jamaica, while about 21% of the children under
one year old showed some degree of malnutrition by Gomez's
classification, more than half of those over one year old were in
this category [6] Earlier studies conducted in Jamaica reported a
similar pattern [7, 8]. It has been hypothesized that the better
nutritional status of infants is probably due to their being able
to satisfy their nutritional needs through breast milk and some
complementary foods. However, after the first year of life, when
breast feeding no longer meets their nutrient needs and
complementary food is inadequate, there is likely to be an
increase in the prevalence of under-nutrition [9].

TABLE 6. Association between
environmental factors and the nutritional status of toddlers

Nutritional
status

N

II

III

III-IV

Water
sourcea

potable

21 (75)

38 (138)

28 (102)

12 (44)

non-potable

16 (19)

29 (34)

26 (31)

29 (35)

Toilet
facilitiesb

sanitary

35 (18)

27 (14)

33 (17)

6 (3)

unsanitary

18 (76)

37 (158)

27 (116)

18 (76)

Water classed as potable if
from community taps or bore wells: as non-potable if from
open wells, rivers, lakes, ponds, etc. x2 =
26.62; P < .01; df = 3.

Toilets classed as sanitary
if outside the house with water supply; as unsanitary if
in the fields or in the house with no water supply. x2
= 17.15; P < .01; df = 3.

TABLE 7. Association between various maternal factors and
the nutritional status of toddlers

TABLE 8. Association between
child factors and the nutritional status of toddlers

Nutritional
status

N

I

II

III-IV

Sex
a

male

23 (56)

39 (94)

27 (66)

11 (28)

female

16 (38)

33 (78)

29 (67)

22 (51 )

Clinical
status b

normal
c

24 (94)

43 (172)

26 (103)

7 (26)

PEM

0 (0)

0 (0)

23 (3)

77 (10)

anaemia

0 (0)

0 (0)

55 (23)

45 (19)

vitamin-A
deficiency

0 (0)

0 (0)

100 (1)

0 (0)

multiple
deficiencies

0 (0)

0 (0)

12 (3)

88 (22)

x2 = 16.94: P
< .01; df = 3.

x2 = 220.5;
p<.001; df = 12.

With no clinical signs of
nutritional deficiency.

The present study corroborates
results from earlier studies that have also found significant
positive associations between high per capita income, maternal
age, and good nutritional status in pre-school children [10-13].
Studies in Mexico, Algeria, and the United States have shown that
a child born to a woman under 20 years old is twice as likely to
die in infancy as one born to a woman in her mid-twenties [13].
Other investigators, however. have not found such an association
[6, 10].

Maternal height and weight were
found to have a significant association with the nutritional
status of the infants. This could be attributed to the fact that
maternal nutritional status is a determinant of lactation
performance and therefore inevitably of the state of infant
nutrition [14].

A number of socio-economic
factors were significantly associated with the nutritional status
of the toddlers. The better nutritional status of those from the
higher castes (those not belonging to the Schedule castes or
tribes) concurs with the findings of earlier studies conducted in
Punjab [15, 16] and Nepal [11]. Per capita income and land
holding were also significantly associated with the nutritional
status of the toddlers. Similar results were reported in a study
conducted in Madhya Pradesh on children 6-36 months old [12].

In the same study from Madhya
Pradesh, as in ours, toddlers from large families had better
nutritional status than those from medium-sized or small
families. It was hypothesized that in large or joint families
there is a greater likelihood of adult women being available to
care for the young children [12]. In contrast, however, other
investigators have found large family size to be significantly
negatively associated with good nutritional status [10, 17]. This
was attributed to the inability of mothers to provide adequate
care for their young children, especially where there was more
than one pre-school child in the family. Also, intra-family
distribution of food was poor, with older family members
receiving the largest share [10].

As in the present study, poor
housing and poor sanitary conditions were found to adversely
affect the nutritional status of children (below four years of
age) in Jamaica [6]. It has been hypothesized that such an
association may be due to the greater frequency of infectious
diseases [18].

The importance of the mother's
education in relation to the health and general well-being of the
child has been stressed by many. Improved levels of maternal
education have been associated with reduced child mortality [19,
20], and low levels of education have repeatedly been found in
mothers of malnourished children [21-23]. In Libya [24] and the
Philippines [10] also, a decrease in the incidence of second- and
third-degree malnutrition among pre-school children was observed
with an increase in the level of education of mothers.

In Madhya Pradesh, the mothers of
the most malnourished groups of children were all working outside
the home [12]. Similar observations in the Philippines were
explained as being due to the mothers' reduced time for child
care, so that, although their increased income made more food
available to the household, the children's nutritional status was
actually worse [10].

Maternal weight was significantly
associated with the toddlers' nutritional status; with an
increase in maternal weight there was a corresponding increase in
the proportion of well-nourished toddlers. Dewey [25] reported
similar findings in Mexican children two to four years old.

The finding that female children
had worse nutritional status than males is consonant with
findings from Bangladesh [2] and the Philippines [10]. Possible
reasons are that males may be seen as an important source of
labour on the family farm; they are expected to provide economic
and social security for their parents when they are old or
incapacitated and in times of distress; and the family name is
carried on by sons and therefore they receive better care than
female children.

It is evident from the findings
of this study that a number of socio-economic, environmental, and
maternal factors play an important role in the nutritional status
of children from birth to three years of age.

Sparling J. Information on
needs of parents with young children. In: A synthesis of
15 child development information research studies from
the administration of children. youth and families -
1980. North Carolina: Child Development Centre.